Handwashing and Habit Formation: A Theory of Behavioral Change

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1 Handwashing and Formation: A Theory of Behavioral Change Reshmaan Hussam, Harvard Business School with Atonu Rabbani, Dhaka University Giovanni Reggiani, MIT Natalia Rigol, Harvard University Global Handwashing Partnership Webinar

2 Handwashing with soap High rates of child stunting and mortality worldwide due to bacterial and viral transmission Diarrhea, ARI 2 million child deaths yearly (WHO 2013) Handwashing with soap the most effective vaccine against childhood infections (World Bank 2005) But handwashing rates abysmally low (3-35%) worldwide, especially during critical times. Why? worldwide rates

3 Why don t people wash their hands? 1 Scarcity of in In interventions have not worked. (WSP 2015, Galiani et al. 2015) People believe washing is important. study context 2 Scarcity of resources Resource interventions, including our own, have not worked. (WSP 2013, Ejemot et al. 2015, SHDS 2015) People have soap and water. study context 3 No health returns in high-disease environments Not true in our setting: handwashing reduces acute respiratory infection and loose stool incidence translates into significant improvements in weight and height People still don t wash. study context

4 Key features of handwashing with soap 1 Preventive activity. Returns are not salient. 2 Not a social norm. No persistent social costs to shirking. 3 Repetitive activity. Repeated engagement is costly...unless it becomes a habit. study context These features apply to many important health activities: water treatment, latrine use, clean cookstove use, etc.

5 : habits and rational addiction Becker and Murphy (1988): A Theory of Rational Addiction 1 : intertemporal complementarities in the utility from consumption 2 Rational habit : Agents are aware of complementarities, so changes in future consumption affect current consumption the model

6 What we do in practice We implement an RCT among 2900 rural households with young children in West Bengal. 1 Our experimental randomizes: whether agents receive monetary incentives, social incentives, only a soap dispenser, or no intervention for daily handwashing habit whether agents anticipate monetary incentives, social incentives, or neither rational habit 2 We observe: precise measure of handwashing behavior before, during, and after withdrawal of the interventions willingness-to-pay for soap child health: diarrhea, ARI, weight, height

7 Measurement technology: from the Media Lab

8 Measurement technology: to the field Introduction

9 Handwashing outcome measure Primary outcome: binary measure of dispenser use during the family s self-reported evening mealtime. Maximize σ by making handwashing amenable to habituation: habit loop: trigger, routine, feedback (Neal et al. 2015)

10 Full sample Incentive villages (IV) Monitoring villages (MV) Households are visited once every two weeks.

11 Incentivized households receive: 1 calendar 2 dispenser to keep 3 soap for one year Incentives intervention 4 tracking of behavior on calendar 5 tickets (one or three) per night dispenser active redeemed for child and household prizes (on day of receipt or later) 1 ticket = Rs. 3 = USD 0.05 Note: tracking measured and incentives earned daily, but recorded and received every two weeks

12 Incentive villages Incentives pure control 1 ticket (2 mo) 1 ticket (2 mo) 1 ticket (2 mo) 3 tickets (2 mo) ANTICIPATE 1 ticket (2 mo) 3 tickets (2 mo) SURPRISE

13 Parallel monitoring experiment Disentangling incentives from feedback alone: Full sample Incentive villages (IV) Monitoring villages (MV)

14 Monitoring intervention Household Receives Incentive Monitoring calendar dispenser to keep soap for one year feedback on calendar tickets

15 Monitoring villages Monitoring pure control dispenser (2 mo) dispenser (2 mo) dispenser (2 mo) monitoring (2 mo) ANTICIPATE dispenser (2 mo) monitoring (2 mo) SURPRISE

16 1 Introduction Roadmap Contemporaneous effects Persistence effects Anticipatory effects 5 6

17 Contemporaneous effects

18 Contemporaneous effects: receiving any tickets increases handwashing at dinnertime Likelihood of using dispenser Likelihood of washing during reported dinner time Day Dispenser control One ticket daily incentive Daytime use Evening use

19 Contemporaneous effects: tripling tickets has little effect on handwashing Fraction of households Fraction of households who used at dinner time Price change Day Standard incentive 3x incentive

20 Contemporaneous effects: monitoring increases handwashing Fraction of households Fraction of households who used at dinner time Monitoring Day Dispenser control Monitoring

21 Persistence effects

22 : previously receiving incentives makes you wash more on extensive margin Fraction of households Fraction of households who used at dinner time 50 Incentives stop Day Dispenser control Former standard incentive Former triple incentive

23 : previously receiving triple vs. single tickets does not persist Fraction of households Fraction of households who used at dinner time 50 Incentives stop Day Dispenser control Former standard incentive Former triple incentive

24 : previously being monitored makes you wash more Fraction of households Fraction of households who used at dinner time 110 Monitoring stops Day Dispenser control Former monitoring

25 Rational habit effects

26 Rational habit : no evidence in households anticipating triple tickets Fraction of households Dinnertime dispenser use: incentives Day Unanticipated 3X tickets Anticipated 3X tickets

27 Rational habit : strong evidence in households anticipating being monitored Fraction of households Dinnertime dispenser use: monitoring Day Unanticipated monitoring Anticipated monitoring Back

28 effects

29 Handwashing decreases loose stool and ARI incidence (1) (2) (3) (4) Any loose stool Total days of loose stool Any ARI symptoms Total days of ARI Received dispenser *** *** ** ** [ ] [0.0236] [0.0154] [0.0884] Mean of pure control [ ] [0.0151] [ ] [0.0504] Observations 3,820 3,830 3,830 3,830 Notes: Observations are at the child level. "Received dispenser" is any household that received a dispenser, pooled over treatment arms. p-values adjusted for multiple hypothesis testing using Anderson (2008). *** p<0.01, ** p<0.05, * p<0.1. disaggregated by age disaggregated by treatment arm Back

30 Handwashing improves child anthropometric outcomes VARIABLES (1) (2) (3) Weight for age z-score Height for age z-score Mid-arm circ. for age z- score Received dispenser 0.135* 0.227* * [0.0640] [0.0902] [0.0518] Mean of pure control [0.0459] [0.0666] [0.0432] Observations Notes: Observations are at the child level. "Received dispenser" is any household that received a dispenser, pooled over treatment arms. p- values adjusted for multiple hypothesis testing using Anderson (2008). *** p<0.01, ** p<0.05, * p<0.1. Back

31 To summarize: 1 Handwashing alone has substantial impacts on child health 2 Financial incentives and monitoring without incentives increases handwashing 3 Handwashing is habitual: effects persist after incentives or monitoring are removed optimal scheme: frontload incentives 4 Agents are rational habit formers: anticipation of a rise in the future likelihood of handwashing increases current handwashing optimal scheme: delay and announce incentives

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